(David McNew/Getty Images)

California has a shortage of physicians, especially in rural areas. It’s a problem which could worsen under federal health care reform. To help address the shortfall, the state Legislature is considering expanding the services that can be provided by nurse practitioners, pharmacists and optometrists. But the proposals face opposition by physicians, who warn that it could hurt the quality of care and would not result in increased services for poor communities.

Guests:
Paul Phinney, Sacramento-based pediatrician and president of the California Medical Association
Ed Hernandez, state senator (D, West Covina) and author of legislation that would expand the scope of practice for certain health practitioners
Debra Bakerjian, senior director of nurse practitioner / physicians assistant clinical education and practice and assistant adjunct professor at the UC Davis Betty Irene Moore School of Nursing

  • Mike

    I am a physician in San Francisco and work with a number of excellent Nurse Practitioners. Despite this, I do not support NP primary care without physician oversight as the biggest errors in medicine occur when providers don’t know when to worry. It is true that for a complicated medical problem a general internist or family medicine MD must know when to refer to a specialist – but this is part of the 30,000 hours of training. An NP, with substantially less training, may not know when they are in over their head. Patients will suffer.

    • Steve

      Sounds like NPs are trying to obtain through LEGISLATION what they don’t feel like working for through EDUCATION – NPs could practice independently anywhere – just do the work and get a medical degree

      • thucy

        I’m all for legislation that would re-intro a Presidential Physical Fitness Program for all Americans. Most of what our for-profit medical system actually treats (at enormous cost to taxpayers) is preventable.
        And now, Steve, let us all take a break from the keyboard and do our workout, thereby alleviating pressure from our overworked “health” care system.

        • Steve

          Don’t get me wrong about my previous or next comments: My NP is way better than the MD. But that’s just MY experience.

          It sounds like all the experts – the doctor, the NP from UC Davis, and even the Senator agree on some things:
          1. a team approach is better than JUST an MD or NP
          2. there is an access problem, especially in rural communities.

          So if the senator would have said,”I want to expand the scope of NPs because they are eminently qualified to do this and the laws are not recognizing that” I would be more behind it.

          BUT- they are proposing this legislation to address an access problem, not to address a problem of NPs being denied practice for which they are qualified but for some reason were overlooked when the laws were written.

          That would be similar to: we have a national airline pilot shortage. We need more pilots, especially in underserved areas. Instead of addressing that, let’s just change FAA rules and let the baggage handlers fly planes in underserved areas.

          No insult – I’m not suggesting such a disparity between MD and NP – but just dramatizing the idea. Why would you change “scope of practice” as they called it to address “lack of practice” – if they need more docs in the rural areas, don’t anoint non doctors to practice, figure out clever ways to get more doctors there, figure out how to train more doctors. Or better yet – train more NPs AND more docs and have more care TEAMs there.

          Just sounds like the legislation serves to lower the bar for care in underserved areas rather than address the actual problem.

      • dj

        Steve – I will respectfully disagree. NPs have extensive education which is broader and more holistic in its scope. Unlike physicians we are able to diversify our practice to bring our patients a wealth of health promoting resources besides the scope of one specialty area. I considered medical school but chose the patient-centered health promotion career of nursing instead. It is true that my training wasn’t 30,000 hours of practice in diagnosing and treating focused on my current specialty area. Instead, my experience ranges from intubating and asperating pneumothoraces in 28 wk newborns to identifying DKA, asthma, absence seizures, eating disorders, domestic violence, PTSD, and countless conditions in the community setting, to diagnosing and treating mental illness in children and adolescents, to managing adult patients on a locked psychiatric unit., Debra Bakerjian is correct in stating that most of us have thousands of hours experience, and patients benefit from our approach to health teaching, thorough patient-centered interviewing (a concept I am glad to see has increased in medical schools).
        The reason I support SB 491 with the appropriate amendment requiring 2-3 years of full time supervised practice (although it could just as well or even better be supervised by another experienced NP) is that the current legislation interferes with our ability to provide much needed care to the patients we ARE qualified to treat- and treat WELL!

        • Michael

          You were trained how to intubate and perform a thoracostomy in NP school? I lived with a student through all of her NP education, and she didn’t learn anything close to this.

          You may have 1000s of hours of experience now, but the point is most NP graduates don’t have nearly that much.
          Lastly, you fail to mention that advanced practice nurses are specialized before they even enter NP school. They have to choose a tract: family practice, adult primary care, adult acute care, nurse midwifery, etc., etc. They are not as broadly trained as they are advertised to be.

          • Chris Waggoner

            Mike, you are talking apples and oranges here. Keep it simple. We are talking about Primary Care, not skills needed for intensive care. I own and operate my own clinic in New Mexico. I was trained at the University of San Diego. My background was ER and Trauma nursing. I have been a NP for over 13yrs. The simple fact is that I am as qualified to provide primary care and appropriate referral to my patients as any primary care physician. I would also caution you to note that I do not see more than 20 patients in a day. Most PCP physicians need to see 30-40 patients to sustain their practice. So physicians have great medical training. How much good does that do with a complex patient and 5-7 minutes in which to assess, diagnose, treat, and educate them regarding their particular condition. You might wish to reconsider your thinking here.

          • Michael

            Most physicians I know and trained with set aside more time for new patients and complex patients and allocated less time (5-10) min for follow-up patients. And it was Deb, not me, who said she could intubate and perform thoracostomy on a 28 wk premature baby as an NP.

          • Chris Waggoner

            Well I just find it amazing that physicians in CA have the time to see 30 to 40 patients in a day, and at the same time “supervise” their NPs on every patient. I would assume that has to be the case, since the president of the CMA stated quite clearly that an NP cannot manage a simple case of knee pain in a pediatric patient. Logic would dictate then that CA physicians who employ NPs must be consulted on every case where the possibility of an expanded differential exists. Really? Sorry docs, but you and every NP in the state of CA know that you have been allowing your NPs to practice independently, and just like any provider faced with a difficult case, you always consult with a colleague or specialist. They still have phones out there don’t they? This is nothing but a simple case of the roosters not wanting to let the hens out of the hen house. You will not lose your status docs, you will only contribute to increased access to health care and better health outcomes in areas where there is a great need for qualified primary care providers (NPs/PAs), along with our ‘highly esteemed” MDs and
            DOs.

          • Chris Waggoner

            Regarding setting aside time for more complex cases, please tell me how you do that when most patients who come in with a complex or emergent condition, usually are booked as a routine visit. Yes, we all have our complex patients that we may allot more time for, but that is not the typical scenario in my experience. They usually come in as a routine visit and are subsequently found to be very sick.

          • Chris Waggoner

            Lastly, let me support the notion of the amendment requiring 2-3 years of supervised practice along with my support of a 1yr residency for NPs. From my early years as an NP, I would consult with more experienced primary care colleagues and review literature on a daily basis due to inexperience with many disease processes. I have always been a champion for any PCP doing a residency. I do think that requirement should be considered as a smart thing to do.

  • WH

    If we are expanding access to millions and do not have enough MDs, expanding the scope of nurse practitioners makes sense. But I have to say, for me and my family, we would prefer to see a MD because we have good insurance and can afford it. But for those who would otherwise not have access to a doctor, they should be able to at least see a nurse.

  • thucy

    As a former health care worker, from a family of MD’s, I’ve been very critical of nurses and the CNA, but largely because I believe nurses are so valuable to the system – almost more so than MD’s.
    Above the level of nurses, Nurse practitioners and PA’s are even more valuable, and they are under-utilized. I’ve consistently received EVEN better care from my PA’s and NP’s than from my MD’s (and my MD’s were excellent.)
    Expanding the reach of nurses, NP’s and PA’s should expand our ability to keep people from becoming sick in the first place. Which should be the point of healthcare, rather than the provision of costly medical procedures.
    I’d also like to push the idea that, more than we need more physicians and nurses, we need more comprehensive phys ed in the schools. Then we could prevent much of the budget-killing T2 diabetes and heart disease. A good fully utilized PE teacher in the public schools should be paid MORE than a nurse.

  • Scott Johnson

    When the deluge of new patients comes next year we could import doctors from Cuba. They train many doctors and they get better health outcomes then our own doctors are able to. Think of the benefit to Cuba of the money they could send home.

    • thucy

      Scott,
      Cuban physicians derive better outcomes because Cuban patients – as poor as they are – are so much healthier than U.S. patients.

  • Peter

    Does anyone other than physicians think the quality of care is higher with MD’s and lower with everyone else? It sounds like ego built in with the education to me.

    • Bill Tutuki

      What about D.O. Doctor of Osteopathy I noticed in some hospitals like Kaiser Vallejo the General Practice Division tend to get assigned to Doctors with D.O. The Specialists are MD’s I know these people. Its really the DO’s Vs. the MD’s who can do medicine better.

  • Michael

    My partner is a Nurse Midwife/Nurse Practitioner who reports most of the
    job listings for NPs are part time jobs. After paying for all those
    years of college, paying off their loans with part time work is expecting a lot. Expanded medical duties would open more jobs for NPs and get more providers for Californians.

    To
    the issue of referring up the chain – I don’t believe NPs will be any
    slower to refer to MDs, than MDs are to refer to specialists. No one
    wants to leave themselves open to lawsuits.

    • Bill Tutuki

      How about Pharmacy Practitioners. I remember looking at some industry chatter between CVS and Rite Aid that they were planning to do this but somehow the Health Insurance and the medical boards objected to it.

  • Livegreen

    Is Senator Hernandez being supported by campaign money from the California Nurses Association? I would like to know if there are any ulterior motives here, especially since there are so many concerns about the legislation.

    • Deb B

      CANP (not CNA) is the organization that is the driving force and they are NOT a rich organization. The primary concerns about the legislation is coming from the CMA who has put a lot of money into fighting the legislation, despite the FACTS. Several consumer organizations, including AARP, have supported and provided funding.

  • The medical schools were being co-opted back into the 1980s. At that time it was known the baby boom would require a proportional increase in physicians. The HMOs back then were strong arming the med schools into lower enrollments so as to have ‘supply & demand’ medical care.

    The current trap is relative to this abuse of both the medical field and the educational system.

  • sam

    As an Emergency physician I have great respect for NPs, but their education/experience is much different from mine and not really comparable. How about better loan forgiveness programs for MDs in rural areas? MDs coming out of school now have >$100K in debt — and they must attend residencies that are very low paying for a minimum of 3 years even for Primary Care. Many primary care docs in “well reimbursed” areas can barely keep the lights on and their kids in school, braces, mortgage in northern CA, etc, etc.

    • Deb B

      There is already loan forgiveness for physicians and, while it has helped some, it is not enough. In many cases, the physicians go to the rural areas but only stay the minimum time and return to urban areas.

  • Michael

    Since my comment didn’t make it on air, I’ll leave it here.

    I am a general surgeon in a state that allows independent practice by nurse practitioners. My fiancée is an adult primary care NP, so I obviously have no problem with NPs. I wholeheartedly agree with Dr. Phinney that NPs are not as qualified as doctors.

    About 50% of my referrals come from NPs. Once concerning trend I’ve noticed is referral to a specialist for things most primary care physicians would be able to manage. I see patients referred for nausea, diarrhea, small hemorrhoids, cellulitis (without abscess), and suspicious breast masses seen on mammography who have not undergone biopsy of the mass. My last office day I saw 12 new patients referred to me and only one actually needed a procedure.

    As one of only two general surgeons serving a rural population of 55,000-60,000, my office is booked out 8 weeks but my surgery schedule isn’t nearly that busy. The patients who actually do need surgery are disadvantaged by my having to spend an entire office day doing what amounts to primary care.
    I rarely get these kinds of referrals from the primary care physicians in town.

  • JM

    I am a nurse practitioner student at UCSF, one of the highest ranking NP schools and while I would like to support the idea of NPs practicing independently, I believe that we need structural changes to our education before that can happen in a safe manner. I would not feel comfortable graduating with a license to practice independently. We only complete around 540 clinical hours and simply need more. A large part of our education is spent learning “research methods and critiquing the literatue”. And we also need to have more residency programs available to nurse practitioners. It is absurd to ask new graduate NPs to step directly out of school and start practicing independently, Physicians have years of supervised training by senior physicians before being allowed to practice independently. At the very least NPs need a 1 year residency program and we need to be supported by our physician colleagues to allow those residency programs to be available to NP graduates. Lastly there needs to be less arguing between the AMA and the BRN regarding this issue and more of a collaborative approach about how we can tackle the problems in our health care system together, how we can find ways for physicians to support the NP practice. We have to learn to work together and to support each others practice.

    • Michael

      My fiancée was also trained at a high ranking NP school. She went out and started to practice on her own and felt incredibly overwhelmed and undertrained. I agree with you completely.

      • thucy

        “She went out and started to practice on her own and felt incredibly overwhelmed.”

        Uh, any young physician would feel similarly overwhelmed were he to go out right after school and start to practice on his own.
        Perhaps the problem was not your fiancee’s training, but rather taking on her own individual practice?

        • Michael

          She didn’t have a choice. She joined a group of primary care docs with the understanding she would work along side them and see their patients in follow-up. They wouldn’t go into detail about her expectations in the employment agreement that she signed. They just said her duties were to work as a provider in the office. Then after a few months she was told she wasn’t busy enough to support her salary and they started putting complex new patients in with her.

          • thucy

            Michael,
            Can we look at this from the perspective of what the population actually needs in order to regain its health? It’s probably not more physicians, but something requiring a lot less training. When you look at what we’re paying to treat, the majority is preventable through diet and exercise. Sadly, neither the AMA nor the CNA would advocate for less business.

          • Michael

            I’ll certainly agree with you on that. One gets a much different perspective on obesity when it’s his job to cut through the fat.

    • thucy

      So… people living in rural communities with no physicians should simply go without ANY care? Sorry, but that obviously hasn’t been working.
      Maybe… after you’ve actually finished school and begin seeing what a sick mess our for-profit system is, you’ll sing a different tune.

    • Kathy

      JM, SB 491 has been amended to assure that new graduates may not practice independently.

    • Deb B

      Yet, the NPs who graduate from that program continue to provide safe care. The hours you talk about are the minimum, many NP students accumulate many more hours. In the UC Davis program, NPs average well over 1500 hours even though our minimum is 980 hours. You might consider that physicians who go into primary care may have too many hours – why do they need to do surgery rotations if they are going to be a primary care doc?

      • Michael

        They need to do surgery rotations so they can learn to differentiate between disease that can be treated medically and disease that requires surgery. They also need it so that they gain an understanding that surgery is not just a black box into which patients go and magically come back cured. A primary care provider should have a very good idea of what is involved for the patient before he makes a surgical referral.
        Another common referral I get is for a patient who actually would benefit from surgery but is so afflicted by comorbid disease that surgery would be more likely to harm the patient than help. Again, good primary care physicians understand this and appropriately do not make the referral in the first place. Many NPs see surgery listed in the treatment options on UpToDate and refer away.
        If you’re going to cut anything out of the education of a primary care physician, it should be the wasted years of liberal arts education. In Europe, medical school is 6 years after high school. Doctors don’t have to understand Sartre to treat disease.

  • Kathy

    I am a psychiatric mental health NP with 38 years of experience, am in solo private practice and on faculty at UCSF. NPs can and do provide comprehensive, safe care. There is a severe shortage of providers in our community. Having more experienced psychiatric nurse practitioners as myself by allowing NPs to practice to the full extent of their education and training will address some of that shortage. SB 491 does not expand scope of practice-it simply eliminates some of the barriers that prevent NPs from practicing.

    I respectfully disagree with Mike- an NP’s training is extensive and part of that training is to know when to refer/confer with our physician colleagues in order to make sure that our patients get the care that they need. NPs will never take the place of physicians, but we need to be smarter about how we deliver care. NPs can fill many of the huge gaps in health care in California.

    • Mike

      I will plead ignorance with the referral system around psychiatric mental health issues. That stated, I am a specialist in hematology/oncology, and I can attest that fielding referrals from MDs and NPs can be very different – why should my clinic time be taken up with a straightforward anemia work-up that an internist could easily perform? Why shouldn’t the NP have to run these questions past an internist? I hope we can both agree that MDs have substantially MORE training in diagnosis and treatment. These comments echo the general surgeon’s (Michael) post below.

      I agree that an NP’s training is extensive, and I work with many outstanding NPs that do a great job with complicated patients. This does not alleviate the need for physicians to be directly involved in a patient’s care.

  • With global warming, it is known that there will be more crises, so more medically trained people will be needed. It is good that this is being discussed, but there must not be a ‘market forces’ approach applied to enrollment.

    The Pentagon and military industrial complex are already planning for food riots and strife due to dislocation by 2020. If medical personnel are limited in stable times due to ‘market forces’ of ‘supply & demand medical care’, disasters should be anticipated and training increased to a larger extent.

  • jennifer Bo

    Listening to Debra Bakerjian was very disturbing- she stated
    a lot of things that are simply not true.” MOST” NP do not have thousands of hours of nursing experience – and even if they do- a nursing job does not equate to training to become an independent practitioner. Also, she kept repeating that the role of NP would not change- yes it will bc they would be independent
    practitioners= THAT is a big change. The training that NP’s are receiving right now does not prepare them to become independent practitioners( no matter how many NP write on this forum that they are trained I can’t agree- it is not an ego issue- if you have doubts you should go ahead and look into the training of
    MD vs NP). It is very unfair for the underserved communities to receive care from individuals who are not trained to practice independently. The many hours of medical school and residency prepares physicians for such work. A lot of
    NP’s are saying that they know when to refer- as Michael pointed out- inappropriate referrals can back up the system and prevent actual ill patients to see a specialist. Again as part of medical school and residency training you get train when to refer and when not to refer- it is really easy to refer out problems when you are not sure what you are dealing with- and that will happen
    a lot more with NP and PA’s who do not have the training.

    I am sorry, from my experience with working with NP and PA- I cannot see them rushing to rural areas to help out. This legislature is based on the premise that NP and PA’s
    will fill the gap in the rural and underserved areas- but we do not have any guarantees that it would happen and again it will not be fair to those patients. To help relieve this problem there needs to
    be more incentive for well-trained physicians to work in rural and underserved areas. I agree with Steve that NP are trying
    to get through legislature what they did not want to do through education- this can be dangerous for patients and that is the bottom line. With our health care insurance providers having no shame and no care for patient safety I can see it
    in our future that they would require everyone to see an NP first and if needed then an MD to save money. As a mother and daughter of an ailing mother- I do not want that happen.

    • Deb B

      Jennifer – I think you should think about what you are saying. 1 year of experience as a Registered Nurse is over 2,000 hours. Most NP students have 5 or more years of nursing experience prior to applying to NP school, many have more years. NPs are trained on when to refer as are physicians. Inappropriate referrals happen – just as frequently by physicians as NPs. The EVIDENCE (many national studies, many done by physicians) show that NPs provide high quality, safe care with equal or better outcomes when compared with physicians and that, in general, referrals are appropriate.

      • jennifer Bo

        Hours of nursing- even in the thousands- does not qualify anyone to work as an independent practitioner. It is interesting to me that so
        many NP think that their education and way of practicing is equal or as some claim superior to MD’s and they constantly reference research!! What they are referring to is the work done by researchers with the Cochrane Database of Systematic Reviews reviewed studies in 2004 and 2009 comparing the relative efficacy of primary care physicians and nurse practitioners. They
        wrote “appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients.” But the important point is that they even admitted that their research was limited.

        Through my own personal experience and also through looking at the training of NP vs MD’s there is no doubt that MD’s are better prepared
        than NP’s and by giving NP ability to practice independently we are ruining the most important field of medicine- Primary care.This area of medicine should be staffed by the best. Unfortunately in medicine primary care does not
        get much respect and trying to get NP to act like MD in field of primary care is another example of lack of respect of medical community for primary care. We need to get more MD’s to work in this field – through this legislature we will deter more MD’s from joining the primary care field and that will only hurt the patients and benefit the NP’s.

  • Richard Osborn

    Kaiser does not hire full-time NPs. They are used as “extenders”. Kaiser doesn’t want to deal with CNA, and so deprives its members of qualified healthcare professionals.

    • erictremont

      The number one reason why Kaiser uses NPs as “extenders” is because most KP physicians like it that way. Rightly or wrongly, they don’t believe that NPs can be “substitutes” for physicians.

  • Beth Grant DeRoos

    Back in the early 1900’s once doctors saw $$$$ in delivering babies they denounced midwives who had been delivering babies for centuries.

    And lord knows in the 1800’s barbers pulled teeth here in the wild west. When groups of special interests see they can make $$$$ they move to make laws that protect just them.

    Not to mention in Europe infant death is lower in countries where babies are not required to be delivered in a hospital. Pregnancy is not a disease!

  • disqus_55xkJELX1R

    I find it odd that as medical professionals we forget to look at the data and rely on anecdotal stories. The evidence supports that NPs provide the same level of care and sometimes superior to physicians. I don’t think NPs would be trying to get independence if there was evidence that they were hurting patients. Healthcare is complex and there will always be errors regardless of training. I’ve had physicians unable to interpret an HIV test, miss simple hyperthyroidism, and even prescribe an inappropriate HIV regimen that would have killed the patient. I don’t particularly blame their training. We just can’t all be experts in everything and mistakes can happen. So if the data shows that NPs provide equal care, then let them practice to that extent. I don’t think NPs or MDs should ever practice by themselves but this law would remove the often-ignored barriers to allow NPs function at their full capacity as part of the greater health care team.

  • Chris Waggoner

    I am an independent practice NP in the state of NM. I currently own and operate my own practice. I was trained in Southern California at the University of San Diego. I have been in practice for over 13yrs. Simply put, denying NPs the right to independent primary care practice in California, denies access to care to potentially millions of patients who are self-pay or on MediCal. There is absolutely no data that the CMA can hold out to justify the continued obstruction of independent NP practice. In my experience, the level and quality of care that NPs provide, quite frankly, is equal to or superior to that of our primary care physician colleagues. The main reason is economics. I limit my practice to 20 patients per day. This gives me more time to assess, diagnose, treat, and educate my patients on their individual medical issues. Most PCP physicians must see a minimum of 30 to 40 patients per day to sustain their practices.

    • Michael

      Is this because your reimbursement is higher, because your overhead is lower, or is there some other reason you can make ends meet when other primary care providers taking care of the same patients need to see twice the volume you do?

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